Wheelchair Documentation Needs (ACA, Face to Face visit is required)The following qualification criteria need to be documented in the patients’ medical record notes to qualify for the prescribed equipment. Note: Face to face and justification notes are valid for six months.

Standard wheelchair – All of the following need to be sufficiently documented to support the need for the prescribed equipment.

Explain the patient’s mobility limitation that significantly impairs (His or Her) ability to participate in one or more mobility-related activities of daily living (MRADL) in the home.
Note: explain the MRADL in detail.

Explain how the patient’s mobility limitation will be sufficiently resolved by the use of a wheelchair and not a fitted cane or walker.

Explain the patient’s home environment.
Note: Must discuss the following- Adequate access between rooms, maneuvering space, and floor surfaces for the use of the wheelchair.

Explain how the use of a wheelchair significantly improve the patient’s participation in MRADLs and will (HE or SHE) use it on a regular basis.

Explain that the patient willing to use the wheelchair.

Explain the patient’s physical and mental ability and/or caregiver situation.
Note: Must discuss the following- patient has sufficient upper extremity function and the physical and mental capabilities needed to safely self-propel the wheelchair or patient has a caregiver who is able to provide assistance.

Lightweight Wheelchair, document the above information and the following.

Explain why the patient is unable to self-propel in a standard wheelchair in the home and why they can self-propel in a lightweight chair.